Baker, William Ralph NEW YORK STATE DEPARTMENT OF HEALTH #S�
Vital Records Section Burial - Transit Permit
Name First ,�//� Ilt Mid Las Se
Date of Death J Age If Veteran of US. Arm F r
®/ War or Dates
P e of Death Hospital, Institution or
C Town or Village �'� Street Address ���JZt' y�Y�
Manner of Death aural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermin ❑Pending
Circumstances Investigation
Medical Certifier Name itl
p 61 h dLl�
€: Death Certificate Filed District Number Register Numl6er
City, Town or Village
Date ,/ or Cremat �y
❑Burial
Address
❑Cremation e
Date Pla6ei Removed
Z ❑Removal and/or Held
••. and/or Address
v5 Hold
Q Date 7 Point of
N❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Nutn
Name of Funeral Home �C�
'< Address /�l � �j"IN
Name o Fun/eral/Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rem s escribed above as indicated.
Date Issued C71��7 aCJO Registrar of Vital Statistics (�
--� / 1 CA,—
s�i�gnat re)
District Number 5(C S a Place 1 D 1N✓� o� L.vt�'S��
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1 o Place of Disposition i%AUk . [v(dr.`
..2 (address)
iu
t>E (section) lot number) (grave number)
0 Name of Sexton or Person in Char e of Premi s ��.
Ssw
g (please print)
Signature Title "'"-
(over)
DOH-1555 (9/98)
Public Health Law Sec. 4145(2b)
0j 3?8Z
Receipt
Human remains of delivered on = ,r , 20 IiJ
Pine View Cemetery `Representifig the funeral lti'ome named,on bufial permit
Official Funeral Directors Reg.or License#''